EVOLVE HESI FUNDAMENTALS EXAM
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The nurse is teaching a client with numerous allergies how to
avoid allergens. Which instruction should be included in this
teaching plan?
A. Avoid any types of sprays, powders, and perfumes.
B. Wearing a mask while cleaning will not help to avoid
allergens.
C. Purchase any type of clothing, but be sure it is washed
before wearing it.
D. Pollen count is related to hay fever, not to allergens. - ✔✔✔
Correct Answer > The client with allergies should be
instructed to reduce any exposure to pollen, dust, fumes,
odors, sprays, powders, and perfumes (A). The client should be
,encouraged to wear a mask when working around dust or
pollen (B). Clients with allergies should avoid any clothing that
causes itching; washing clothes will not prevent an allergic
reaction to some fabrics (C). Pollen count is related to allergens
(D), and the client should be instructed to stay indoors when
the pollen count is high.
Correct Answer: A
A client who is in hospice care complains of increasing amounts
of pain. The healthcare provider prescribes an analgesic every
four hours as needed. Which action should the nurse
implement?
A. Give an around-the-clock schedule for administration of
analgesics.
B. Administer analgesic medication as needed when the pain is
severe.
C. Provide medication to keep the client sedated and unaware
of stimuli.
D. Offer a medication-free period so that the client can do daily
activities. - ✔✔✔ Correct Answer > The most effective
management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis
,(A) and in a timely manner. Analgesics are less effective if pain
persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing
comfort is a priority for the client who is dying, but sedation
that impairs the client's ability to interact and experience the
time before life ends should be minimized (C). Offering a
medication-free period allows the serum drug level to fall,
which is not an effective method to manage chronic pain (D).
Correct Answer: A
When assessing a client with wrist restraints, the nurse
observes that the fingers on the right hand are blue. What
action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - ✔✔✔ Correct Answer
> The priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis)
indicates decreased circulation. (C and D) are also important
nursing interventions, but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of hemoglobin with
, oxygen and is not indicated in situations where the cyanosis is
related to mechanical compression (the restraints).
Correct Answer: A
On admission, a client presents a signed living will that includes
a Do Not Resuscitate (DNR) prescription. When the client stops
breathing, the nurse performs cardiopulmonary resuscitation
(CPR) and successfully revives the client. What legal issues
could be brought against the nurse?
A. Assault.
B. Battery.
C. Malpractice.
D. False imprisonment. - ✔✔✔ Correct Answer > Civil
laws protect individual rights and include intentional torts, such
as assault (an intentional threat to engage in harmful contact
with another) or battery (unwanted touching). Performing any
procedure against the client's wishes can potentially pose a
legal issue, such as battery (B), even if the procedure is of
questionable benefit to the client. (A, C, and D) are not
examples against the client's request.
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